U C O N N H E A LT HJournal Fall 2019

The breast cancer journey is a

delicate one. UConn Health's

breast team guides each patient

through every step with an

unmatched level of attention. p.10

UConn and Foundation for Prader-Willi Research Create Stem Cell Biobank 4

Better Urologic Cancer Detection 3

Elevated Expertise in Spinal Oncology Surgery 8

This spring, U.S. News & World Report named UConn School of Medicine among the 10 medical schools nationwide with the most African American students, a validation of the School’s efforts to grow the diversity of its student body.

The School’s African American student population for 2018–2019 was 11.8%, well above the national average for medical schools. The national average, which was 6% in 1980, is now 7.1%.

“The lack of African Americans and other underrepresented minorities choosing to enter the fields of medicine and research is a critical and longstanding national issue,” says Dr. Bruce T. Liang, dean of UConn’s medical school. “We look forward to further helping curb this national issue and building a stronger, more diverse pipeline of future health care professionals through our medical educational mission and training initiatives.”

Research has shown that racial and ethnic diversity in medical education improves the learning and cross-cultural competencies of all doctors. And minority medical students are more likely to work in underserved communities and, therefore, positively influence access to care.

UConn School of Medicine has worked for decades to increase

diversity, with much success. With this year’s incoming class, the medical school’s underrepresented-population enrollment is expected to reach a height of nearly 23%. For more than a decade, UConn’s medical school has maintained its overall percentage of African American students

and has doubled the number of black males enrolled.

Having among the highest number of African American students “is very gratifying,” says Dr. Marja M. Hurley, founding director and

associate dean for the Health Career Opportunity Programs at UConn Health, sponsored by the Aetna Health Professions Partnership Initiative. For nearly two decades, these programs have aimed to attract more young people from across Connecticut, of all ethnic and socioeconomic backgrounds, to medicine and science.

Of the nearly 900 youth from the state’s elementary schools, high schools, and colleges who have participated in the programs since 1996, more than 500 have gone on to enter medical, dental, or other health profession schools. Among the School of Medicine Class of 2019, 66% of the African American graduating students participated in one or more of the programs.

“We are very proud of the successes in growing the diversity of our student body, and also building a greater pipeline for a more diverse future health care workforce,” says Hurley.

Liang added: “This is very good recognition for the UConn School of Medicine and the excellent work of our medical school’s Student Affairs team and Dr. Marja Hurley.”

1

UConn Health Journal is a publication of University Communications at the University of Connecticut. Vice President for Communications: Tysen Kendig Associate Vice President for Creative Strategy & Brand Management: Patricia Fazio Editor: Julie Bartucca Art Director: Yesenia Carrero Photographers: Sean Flynn, Peter Morenus, Kristin Wallace Lead Science/Health Writers: Kim Krieger, Lauren Woods Contributing Writers: Courtney Chandler, Chris DeFrancesco, Stacey Mancarella, Jessica McBride, Delker Vardilos Cover: Stan Godlewski for UConn Health

Handled With Care 10The breast cancer journey is a delicate one. The team at Beekley Imaging Center and the Carole and Ray Neag Comprehensive Cancer Center strives to guide each patient through every step of their individual path with an unmatched level of attention and comfort.

Features Departments

UConn Health Leads Search for Syphilis Vaccine 6

Dental Researchers Attack Painful Chemo Side Effect 7

UCONN EXAMINES

Healthy Aging Dr. George Kuchel, director of the UConn Center on Aging, discusses the key phases of geriatric care. 16

THE DOCTOR IS IN

Dr. Kwame Amankwah New chief of vascular surgery chief stays a step ahead. 17

THE PULSE

Honor RollWe celebrate UConn Health's accolades. 2–6

Follow-Up Research doesn’t stop once we report it. Read updates on past stories. 2

ConnectiCare Passage Plan Patients Now Accepted 2

Better Urologic Cancer Detection 3

UConn and Foundation for Prader-Willi Research Create Stem Cell Biobank 4

Lab NotesThe future of health care advancement is already here. 4–5

Find us online: healthjournal.uconn.edu

The University of Connecticut complies with all applicable federal and state laws regarding non-discrimination, equal opportunity and affirmative action, including the provision of reasonable accommodations for persons with disabilities. UConn does not discriminate on the basis of race, color, ethnicity, religious creed, age, sex, marital status, national origin, ancestry, sexual orientation, genetic information, physical or mental disability, veteran status, prior conviction of a crime, workplace hazards to reproductive systems, gender identity or expression, or political beliefs in its programs and activities. Employees, students, visitors, and applicants with disabilities may request reasonable accommodations to address limitations resulting from a disability. For questions or more information, please contact the Associate Vice President, Office of Institutional Equity, 241 Glenbrook Road, Unit 4175, Storrs, CT 06269-4175; Phone: (860) 486-2943; Email: equity@uconn.edu; Website: www.equity.uconn.edu. Fall 2019

COVER STORY

Unparalleled 8Dr. David Choi is the only neurosurgeon in Connecticut who is fellowship-trained in spinal oncology surgery. His arrival enables patients dealing with the pain and adverse impacts of spinal tumors to stay close to home for their treatment.

THE POWER OF POSSIBLE IN THIS ISSUE

— Dr. Bruce T. Liang, Dean, UConn School of Medicine

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High school research apprentices attend a Health Care Opportunity Programs symposium in July.

UConn Health urologists are at the forefront of new and improved approaches to detecting prostate and bladder cancer, the first and fourth most common forms of cancer among men.

When a patient needs a prostate biopsy, the urology team is among the first in New England to practice a new method called transperineal prostate biopsy, which offers distinct advantages in safety and precision over previous protocols.

Historically when a biopsy was needed, urologists would pierce the rectal wall with a needle to take a biopsy of the prostate. Known as a transrectal biopsy, the procedure carries a small but real risk of infection. Roughly three out of every 100 men who undergo a transrectal biopsy end up in the intensive care unit with sepsis, a potentially life-

threatening condition related to the body’s response to infection.

“The other problem with the transrectal approach is the difficulty accessing some portions of the prostate,” says Dr. Peter Albertsen, chief of UConn Health’s Division of Urology. “The angle of the biopsy needle traversing the probe makes it hard to hit the apex of the prostate.

With the transperineal approach, we are finding it much easier to access regions of the prostate which historically have been difficult to reach with a transrectal probe.”

With transperineal biopsy, the needle that retrieves the tissue

sample goes not through the rectum but the soft tissue just outside and past it, guided by the latest ultrasound technology for a clear, real-time view.

“Fortunately there are no nasty blood vessels, there are no nasty nerves, and it’s a straight shot to get” to the prostate, Albertsen says.

“And by not going through the rectum, we anticipate the risk of sepsis going to zero.”

For bladder cancer detection, the urologists are the first in central Connecticut to use a new blue light cystoscopy technology to illuminate tumors in the bladder and identify smaller cancers earlier than ever before.

Certain tumors are hard to detect using traditional white light cystoscopy, but turn pink under the enhanced imaging provided by the blue light.

“Recurrence rates for bladder cancers are somewhere in the 50–70% range. Using blue light cystoscopy, depending on the tumor type, can reduce the risk of recurrence by about 40%, which means fewer trips to the operating room,” says Dr. Benjamin Ristau, UConn Health’s surgical director of urologic oncology.

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H O N O R R O L L

Connecticut Magazine’s 2019 Best Doctors issue includes 48 UConn Health physicians, while six UConn Health dentists made the magazine’s Top Dentists list. To see who was named, visit s.uconn.edu/bestdocs19 and s.uconn.edu/dentists19

Nancy Dupont, MPH, BSN, RN, received the 2019 Association for Professionals in Infection Control and Epidemiology (APIC) Chapter Leader Award for her achievements in developing the APIC New England Chapter member community and in advancing infection prevention.

Dr. Cato T. Laurencin was the first UConn Health faculty member to be elected to American Academy of Arts and Sciences.

Fall 2019

F O L L O W - U P

UConn Health’s milk depot collected more than 12,000 ounces of donated breast milk in its first year, providing approximately 37,000 meals for premature babies. The depot, opened in August 2018, is the first at a Connecticut hospital and the only one in the greater Hartford area to join Mothers’ Milk Bank Northeast. The nonprofit community milk bank, accredited by the Human Milk Banking Association of North America, distributes donated, pasteurized human milk to babies in fragile health throughout the Northeast.

Visit healthjournal.uconn.edu/archive to read the original story from Fall 2018.

Breast Milk Donations

UConn Health Journal

Better Urologic Cancer Detection

Physicians at UConn Health recently began accepting ConnectiCare passage plan patients. “Passage” plans are referral plans offered by ConnectiCare to commercial and Medicare Advantage members. Members of passage plans are required to get primary care provider (PCP) referrals to see any specialist in the ConnectiCare network. For assistance on referrals and general information, contact practicerelations@uchc.edu.

THE PULSE

— Dr. Peter Albertsen, urology chief

“

“

When do doctors need to submit a referral? When a patient needs specialist care, a referral must be submitted before the patient goes to see that specialist. One referral is required for office visits for each different specialty. However, a referral isn’t needed for each visit to the same specialist.

For example:1. If the patient needs to see a

dermatologist and a cardiologist, a separate referral must be entered for each specialist.

2. If the patient’s dermatologist refers the patient to a surgeon, the patient will need another PCP referral for the surgeon.

3. If the patient needs to see a dermatologist six times, only one referral is needed. Referrals should be submitted with start and end dates that allow the patient enough time to see the dermatologist six times.

Dr. Ben Ristau uses ultrasound to guide a transperineal prostate biopsy.

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L A B N O T E S

CAUTION: FALLS AHEAD

Antidepressant drugs known as selective norepinephrine reuptake inhibitors, or SNRIs, can lead to adverse events in adults over 65, according to a team of researchers from UConn School of Pharmacy, UConn Health, and Yale University. Among this drug class, duloxetine, which is commonly known as Cymbalta, was shown to most likely increase

the risk of falls over time, according to the study published in the Journal of the

American Geriatric Society. SNRIs, particularly duloxetine, should be avoided or used

with caution in older adults, the researchers say.

JUST BREATHE

Yoga practice that emphasizes mental relaxation and breathing techniques can have as much of a beneficial impact on high blood pressure as aerobic exercise, according to research by Yin Wu, Ph.D., a postdoctoral fellow in UConn’s Department of Kinesiology. The study, published in Mayo Clinic Proceedings, highlights the potential for yoga as an alternative antihypertensive

therapy, particularly for those unable or unwilling to perform aerobic exercise. “We

are not telling people to use yoga to substitute for aerobic exercise,” says Wu. “Aerobic exercise is the gold standard for antihypertensive lifestyle therapy. But yoga provides an additional option that can be just as effective.”

HALTING HYPERTENSION’S EFFECTS

Elderly people with hypertension who took a high dosage of medicine to manage their high blood pressure showed significantly less accumulation of harmful brain lesions compared to those taking a lower dose of the same medicine, UConn Health researchers reported at the American College of Cardiology’s 68th Annual Scientific Session. However, the reduction in brain lesions did not translate to a significant improvement in mobility and cognitive function. The INFINITY study is the first to demonstrate an effective way to slow the progression of cerebrovascular disease, a condition common in older adults that restricts the flow of blood to the brain. In addition to seeing beneficial effects in the brain, those who kept their blood pressure lower also were less likely to suffer major cardiovascular events, such as a heart attack or stroke.

UConn Health Journal

H O N O R R O L L UConn and Foundation for Prader-Willi Research Create Stem Cell Biobank

skin, stomach, brain, blood, and more. The biobank will be able to supply induced-pluripotent stem cells for Prader-Willi syndrome to researchers throughout the world.

Prader-Willi syndrome occurs in approximately 1 in 15,000 to 30,000 births. It’s caused when certain genes that are normally found on chromosome 15 are missing or not working. In most individuals with Prader-Willi syndrome, certain genes on chromosome 15 that should be specifically expressed from the father’s chromosome are missing. Geneticists don’t understand why, but the mother’s version of these genes is always turned off.

It’s these genes, and how their absence affects the rest of the genome’s and cells’ functions, that researchers will be able to investigate

thanks to the biobank. Researchers will be able to use the induced-pluripotent stem cells to look for potential therapies for Prader-Willi syndrome. They may also be able to use the cells to explore the genetic

and biomolecular basis of some of the syndrome’s symptoms, such as sleep disorders, developmental delays, and disordered eating.

UConn will host the centralized repository in the Stem Cell Core on the UConn Health medical school campus. Each Prader-Willi syndrome

induced-pluripotent stem cell sample provided through the biobank will have undergone a select set of validation assays. The biobank will help facilitate research on cellular phenotypic abnormalities in Prader-Willi syndrome and ensure that precious research dollars are not

spent re-creating stem cell resources that may already exist.

“The objective of FPWR’s translational research program is to reduce the amount of time and resources needed to move therapeutic studies forward,” says Nathalie Kayadjanian, director of translational research at FPWR. “Stem cells stored at the UConn Core will provide Prader-Willi syndrome researchers and pharmaceutical companies pursuing Prader-Willi syndrome therapeutics high-quality cellular resources to perform robust experiments in a timely manner.”

Currently the Prader-Willi syndrome biobank has two cell lines, one with a deletion of certain genes on the father’s copy of chromosome 15, the other with two copies of chromosome 15 from the mother and none from the father. Both cell lines were contributed by Stormy Chamberlain, Ph.D., and Marc Lalande, Ph.D., UConn Health researchers who study Prader-Willi syndrome and its sibling genetic disorder Angelman’s syndrome. More cell lines will be banked at the facility in the coming years.

— Nathalie Kayadjanian, Foundation for Prader-Willi Research

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Dr. Jacqueline “Kiki” Nissen received the 2019 UConn Health Board of Directors Faculty Recognition Award.

At its annual meeting, The Academy of General Dentistry honored Dr. Hsung Lin with its highest, most prestigious honor, the Mastership Award. Clinical Assistant Professor Dr. Steve Ruiz received the Fellowship Award.

THE KEY TO ALLERGIES

An unexpected source drives severe allergies, researchers from UConn Health, The Jackson Laboratory for Genomic Medicine, and Yale University report in Science. An antibody known as high-affinity IgE is often behind the most severe food allergies, triggering anaphylactic shock. The researchers looked at mice with a genetic immune problem that causes severe food allergies including anaphylaxis. They found a subtype of immune cells called Tfh13 signal to B cells, another category of immune cell, telling them to make high-affinity

IgE. When the researchers deleted Tfh13 cells in mice, the allergies disappeared. People with severe allergies tend to have elevated Tfh13 levels compared with nonallergic peers.

The findings could point the way to better allergy testing and perhaps new approaches for treating allergies.

THE PULSE

A new collaboration between UConn Health and the Foundation for Prader-Willi Research will create a centralized, high-quality biobank of stem cells to help researchers better understand Prader-Willi syndrome, a rare genetic disease that may hold insights into obesity, developmental delays, autism spectrum disorders, and many other conditions.

The foundation (FPWR) and the UConn–Wesleyan University Stem Cell Core will jointly support the biobank of induced-pluripotent stem cells for Prader-Willi syndrome. These special stem cells are made from adult cells, and they have the potential to grow into any bodily tissue, including

Fall 2019

Stem cells provided through a new biobank hosted at UConn will allow researchers around the world to better understand Prader-Willi syndrome and look for potential therapies for the rare genetic disease.

Yalin

g L

iu

UConn Health Leads Search for Syphilis VaccineWhile cases of syphilis in Europe first were recorded over 500 years ago, no vaccine candidates have ever advanced to human clinical trials. A new, international center led by the UConn School of Medicine and the Connecticut Children’s aims to change that.

UConn will receive up to $11 million over five years from the National Institute

of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health (NIH), to develop a vaccine for this centuries-old disease.

Syphilis poses serious health consequences internationally and in the United States. The World Health Organization (WHO) estimates that 10.7 million people between the ages of 15 and 49 had syphilis in 2012, and about 5.6 million people contract it every year.

“An effective syphilis vaccine would represent a triumph for biomedical research over an ailment that has defied conventional public health strategies for prevention and control,” says Dr. Justin Radolf, professor of medicine and pediatrics at UConn School of Medicine and co-principal investigator with Dr. M. Anthony Moody of Duke University. “If successful, the scientific and public health impact of our approach will extend well beyond syphilis and establish a model to tackle other pathogens.”

Syphilis is primarily transmitted through direct contact with an infectious lesion during unprotected sex, and can also be passed from expecting mothers to their unborn children. Syphilis is the second leading cause of stillbirth and miscarriage worldwide. If left untreated, it can cause strokes, dementia, and other neurological diseases in any infected person.

Past attempts to control the syphilis epidemic by treating infected individuals and their partners have proved unsuccessful, largely due to difficulties diagnosing the disease, limited access to care for certain high-risk individuals, and limited resources

for effective contact investigation. Furthermore, syphilis and HIV are recognized as “syndemics,” in which both infections can increase the risk of acquisition and transmission of the other.

The international study team comprises researchers from UConn School of Medicine; Connecticut Children’s; the Duke Human Vaccine Institute; the University of North Carolina (UNC) at Chapel Hill Institute for Global Health and Infectious Diseases; UNC Project-Malawi; Masaryk University in the Czech Republic; and Southern Medical University in Guangzhou, China.

“This center combines the unique capabilities of UConn Health’s Spirochete Research Lab with the rest of the study team, which has world-class vaccine research infrastructure, international health expertise, and unparalleled knowledge of bacterial genomics to achieve our long-term objective,” says Dr. Juan Salazar, chair of pediatrics at UConn Health and physician-in-chief at Connecticut Children’s.

An estimated 400,000 U.S. patients undergoing chemotherapy and radiation therapy each year develop painful mouth sores known as oral mucositis. Researchers across UConn are attacking this common side effect from several angles, with one team working to understand the root causes of the ulcers and another developing a better way to treat them.

Cancer drugs break down the mucous membranes lining the mouth, called oral mucosa, inducing painful lesions that can cause difficulty talking, swallowing, and eating. The pain can

become so severe that patients require feeding intravenously or through a stomach tube. Other risks to patients include slower healing, decreased

resistance to infection, and general failure to thrive. Secondary infection and potentially life-threatening systemic sepsis have also been reported.

One UConn School of Dental Medicine research team published in Springer Nature’s Microbiome the most comprehensive study to date about the patho-physiology of oral mucositis in humans due to the effects of chemotherapy.

The team, led by Dr. Patricia Diaz, associate professor in the Department of Oral Health

and Diagnostic Sciences, found that patients who developed the most severe lesions showed suppression of beneficial mouth bacteria and outgrowth of harmful ones.

Further studies are needed to understand which specific microbiome components are detrimental and in what manner they affect the oral mucosa’s ability to withstand a chemotherapy challenge.

Meanwhile, Dr. Rajesh Lalla, professor of dental medicine, is collaborating with UConn Board of Trustees Distinguished Professor of Pharmaceutical Sciences Diane J. Burgess, graduate student Tingting Li, and drug design firm Cellix Bio to develop a new, long-acting topical anesthetic that he hopes will someday replace current methods of treating oral mucositis.

The current first-line therapy at most U.S. hospitals is a mouth rinse containing the local anesthetic lidocaine, providing about 30 minutes of relief. The rinse numbs the entire mouth instead of focusing specifically on the sores, which poses safety concerns since it can inhibit the swallowing reflex. Patients are also often prescribed systemic opioids to treat the pain.

The team has developed an innovative formulation and novel patented compound that allows a long-acting topical anesthetic to be applied directly to sores. The researchers expect the more potent anesthetic should relieve pain for about four hours, eight times as long as the standard mouth rinse.

The compound also exhibits antimicrobial and anti-inflammatory effects naturally delivered by the medium chain fatty acid, which could reduce the severity of lesions from oral mucositis, says Lalla.

Lalla and his collaborators believe they are one to two years away from clinical trials in humans.

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H O N O R R O L L

Dr. Andrew Arnold received the FIRMO Parathyroid Medal at MEN 2019: The 16th International Workshop on Multiple Endocrine Neoplasia for his research on parathyroid glands.

Dr. Marja Hurley was appointed to The American Society for Bone and Mineral Research Council.

The Research Society of Alcoholism has awarded Dr. Victor Hesselbrock its 2019 RSA Seixas Award for Service.

UConn Health faculty researchers Dr. Emily Germain-Lee, Dr. Se-Jin Lee, Dr. Annabelle Rodriguez-Oquendo, and Riqiang Yan, Ph.D., are among 24 newly elected members of the Connecticut Academy of Science and Engineering.

UConn Health Journal 7

Dr. Juan Salazar, left, and Dr. Justin Radolf in Radolf's lab at UConn Health in Farmington.

THE PULSE

Fall 2019

While the pain that oral mucositis causes is certainly of great concern, perhaps the most harmful impact occurs when patients are in such extreme agony that their attending physicians have no choice but to prescribe undesirable dose reductions or treatment breaks in cancer therapy.

— Dr. Rajesh Lalla of the UConn School of Dental Medicine, who is developing an improved oral mucositis treatment

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UConn Health Journal8

hen a man in his sixties recently went to UConn John Dempsey Hospital after four days of severe back pain, an MRI revealed a rapidly growing spinal cord tumor that was placing

extreme pressure on his spine.He was sent straight to the emergency

department where Dr. David Choi, the only neurosurgeon in Connecticut with fellowship training in spinal oncology, met him.

But not for the first time.“Because we’re local, I had been seeing this

gentleman for months before this tumor problem arose, so I already knew who he was, I already knew what treatments he was going through, I knew his general attitude about the quality of life that he would want for himself,” Choi recalls. “Now thankfully he did not have any neurologic deficits, but there was just so much compression on the spinal cord that I didn’t want to wait for anything bad to happen.”

Right away — in the middle of the night — Choi operated to decompress the tumor and stabilize the spine with rods and screws.

“The decision to do surgery was a no-brainer for both of us,” says Choi. Before Choi, the product of an elite complex spine surgery fellowship at Brown University, arrived at UConn Health, patients like this one had to travel to Boston or New York City for the same level of fellowship-trained expertise.

Having a comprehensive spine surgery specialist like Choi provides “real-time coverage — you’re getting things done right as they happen, and that gives the best chance for improved outcomes,” he says.

It’s an example of a patient already under the care of familiar providers being able to stay at UConn Health for continuation of that care, including treatment by a spine surgeon with unique subspecialty training in treating spinal tumors.

“In some cases, tumors cannot be entirely removed, requiring further treatments after surgery, such as chemotherapy and/or radiation therapy, coordinated by oncologists and radiation oncologists,” Choi says. “In cases of metastatic tumors, other surgical tumor specialists may continue their involvement in treating the primary tumor.”

Spinal tumors can metastasize to the spine or originate in or around the spinal cord or in the vertebrae. A tumor in the bone can cause fractures and a partial collapse of the spinal

cord. In extreme cases, fractured pieces of bone may affect the spinal cord and

cause neurologic deficits such as limb weakness or incontinence. Similar neurologic defects can result from a tumor in or around the spinal cord, which can compress the spinal cord or the nerve roots that exit it.

“The possible permanence of these deficits makes surgery necessary,” Choi says. “If you’re not able to walk around, or if you have bowel or bladder issues, that’s a pretty big impact on quality of life for the rest of your life.”

Choi says the opportunity to shape spinal oncology care at UConn Health is what drew him to Farmington.

“Few physicians will have a chance to help develop a new division in a

well-established institution,” he says. “UConn Health is poised to become a

leading destination center for a wide variety of neurosurgical conditions, and

spinal oncology is a field that will serve our community and state well.”

Choi’s addition is a cornerstone of the vision of Dr. Ketan Bulsara, chief of

the Division of Neurosurgery, to expand UConn Health’s neurosurgical care

offerings and make UConn a world-class destination center.

“Dr. Choi’s expertise adds to the excellent work that was already being done at UConn

Health in collaboration between neurosurgery and orthopedic surgery through our

comprehensive spine center,” Bulsara says. “His level of training allows him to offer a unique

perspective and potential treatment options for spine/spinal cord tumors.”

It also adds to a multidisciplinary team of spine surgeons at UConn Health.

“The recruitment of his talent and clinical expertise buttresses the vision of our

comprehensive spine program,” says Dr. Hilary Onyiuke, neurosurgical director of UConn Health’s Comprehensive Spine Center.

The elite skill of the growing neurosurgery program is expanding in other ways as well.

Dr. Kevin Becker recently came from Yale to build a neuro-oncology program in collaboration with the Department of Neurology and the Carole and Ray Neag Comprehensive Cancer Center. Bulsara says the arrival of Becker “continues to build on our collaboration with the Preston Robert Tisch Brain Tumor Center at Duke, bringing an additional dimension to our treatment paradigm.”

Unparalleled New Doc Brings Elevated Expertise in Spinal Oncology Surgery

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9Fall 2019

Some people need no urging to get medical screenings. These are the people who see their dentist twice a year like clockwork, who make that annual preventive care appointment, and who don’t put off a colonoscopy.

But most people are not like that. Even a mammogram can be a tough sell. Getting your breasts squeezed between two cold plates and X-rayed while wearing an ill-fitting gown is nobody’s idea of a good time. And when a patient has already found a suspicious lump, there’s an extra layer of stress.

The radiologists and staff at UConn Health’s Beekley Imaging Center, part of the Women’s

Center, do their best to dispel that stress. Good service and a relaxing atmosphere go a long way toward evoking a spa-like ambience. There’s comfortable seating, private changing rooms, warmed gowns that fit, appointments that start on time — and cookies.

The patients appreciate it.“I’m always in and out,”

one woman says to another as they ride the elevator up to the imaging center.

“I stay for the cookies and juice,” says the other. They both laugh. The first woman proclaims, “It’s really nice up there!”

Indeed it is. And if a woman

The breast cancer journey is a delicate one.

The breast team at UConn Health strives to

guide each patient through every step of their

individual path with an unmatched level of

attention and comfort.

UConn medical oncologist Dr. Susan Tannenbaum initiated the multidisciplinary focus of the breast program, connecting patient care to research and bringing accreditation through the American College of Surgeons, before handing the reins to surgeon Dr. Christina Stevenson.

By Kim Krieger Photos by Peter Morenus

11Fall 2019

13

cares to linger over her cookies and juice, she can get her results on the spot.

“One woman, here in 2013, 2015, 2017, 2019, always reports the same symptoms. Lumps, terrible breast pain. She wants our attention. She is worried about breast cancer,” says Dr. Alex Merkulov, head of women’s imaging and a radiologist in the Imaging Center. “Our job is to remind her of the prior years and assure her that everything is OK this time, too. We treat people the way we would want to be treated.”

Merkulov is intensely attentive when you talk to him, and although his phone dings constantly, he gives you the feeling that all his focus is on you. However much time you need. He says working with each patient “is a personal

relationship.” And he means it.

All a woman needs to start this relationship is an order for a mammogram from her primary care doctor. She makes an appointment and fills out a short questionnaire when she arrives. Does she have a lump? Pain? Have any family members had breast cancer? Depending on her answers to the questionnaire and the results of her mammogram, the radiologists may recommend she come in for more frequent screenings or have a consultation with one of the genetic counselors.

After her low-dose mammogram, the woman dresses, gets her cookies

and juice, and hears her results within 15 minutes. If she’s in a hurry, she can leave immediately and get a phone call within two days letting her know if she needs any follow-up tests.

Most of the time, those results are A-OK. The radiologist gives the all-clear and says, “See you in two years.”

Only about 10% of women have something in the mammogram that might indicate a problem. When that happens, the radiologist recommends a follow-up ultrasound or a special mammogram to detect the calcium deposits that can signal early breast cancer.

“I’m a frequent flyer” at the Beekley Imaging Center, says a patient named Patricia. Because she’s at high risk for breast cancer, she’s had tests often over the last 10 years. At some places she’s had mammograms, “you go in a basement, you don’t talk to anyone, you get a letter a week later,” she says. But UConn Health is completely different.

When she first started going, they modeled her risk. Patricia’s was off the charts, so they had her meet with a medical oncologist at the Carole and Ray Neag Comprehensive Cancer Center who specializes in breast cancer to discuss preventive options. After examining Patricia’s history in detail, the oncologist, Dr. Susan Tannenbaum, advised her that actually, she didn’t need to proceed with preventive medical oncology. On other visits, the radiologist has invited her into his office to view the mammograms displayed on big screens so he can show her exactly what he sees and explain why he is

or isn’t concerned. “They give you a lot of

information in a caring way,” Patricia says. “I have too much going on to have my primary care doctor and OB/GYN booking appointments randomly — I need a team treating me holistically. This feels like intimate care from really great doctors.”

That focus on intimate, holistic care is evident even when a woman has a benign breast condition. Women with breast pain, breast infections, fibroadenomas, and other

lumps that aren’t cancer see Dr. Dana Scott, an OB/GYN who specializes in benign breast conditions. The benign breast disease program she leads is unique in the area.

“I try to really listen to my patients and spend the appropriate amount of time with them to hear all their concerns,” Scott says. Sometimes the women need treatment, sometimes even surgery. But just as often, it’s the care and attention they get that is the most valuable. For “a lot of patients who are really worried they have breast cancer and they don’t, having someone who can listen to them, examine them, and provide

follow-up is really important,” Scott says.

But what if a woman’s breast condition isn’t benign? If the follow-up scans reveal something that looks suspicious, the radiologists discuss the findings with the woman and advise her to come in for a biopsy, scheduled at her convenience for some time in the next day or two.

The tissue from the biopsy is evaluated by Dr. Poornima Hegde, a UConn Health pathologist who specializes in breast disease. A cancer diagnosis is only as precise at the pathologist who evaluates the suspicious cells, and Hegde is an expert. She looks at breast tissue all day, every day, and can make the call between cells that are just a little weird versus cells that mean malignancy.

“We try to reduce the ambiguity: either you’re OK, or you’re not,” says Merkulov, the radiologist. “Poornima is a godsend.”

If Hegde and the radiologists agree the woman has a cancerous mass, they spring into action. They contact the breast cancer nurse navigator and, often, the team’s social worker and bring them in to discuss the results of the biopsy with the patient. The nurse navigator will call the patient and answer any preliminary questions she has. The navigator also tries to identify any hurdles or barriers the woman might have to overcome to get treatment.

“You need to understand where people are coming from: people may have the exact same diagnosis but very different resources,” says Wendy Thibodeau, RN, one of the nurse navigators

“We treat people the way we want to be treated,” says Dr. Alex Merkulov, head of women's imaging and a radiologist in the Beekley Imaging Center. The large screens in the Center's imaging suite allow radiologists to show patients exactly what they're seeing after a mammogram and explain why they are or are not concerned.

Fall 2019

Sometimes we have

a patient whose

f i rst inst inct is ‘Cut

i t off ! ’ I explain

you can’t just cut;

you need tests to

understand what we

need to do to treat

this . Not al l cancers

are the same.

12 UConn Health Journal

13Spring 2019

who works with breast cancer patients. Thibodeau speaks plainly, and intuitively grasps what you’re really asking with a question. Her role as a navigator is to coordinate care for the patient, offer her emotional support, evaluate any barriers to treatment, and help her get to the next step. She gives every patient her cell phone number and tells them they can call her anytime. Often, they call her to ask her to remind them what the doctor said, what they need to do. But other times, she must talk them down.

“Sometimes we have a patient whose first instinct is

‘Cut it off! Cut it out of me!’” Thibodeau says. “I have to call her and explain you can’t just cut; you need to do lots of tests to understand what we need to do to treat this.” Sometimes a woman will need chemotherapy before surgery to shrink the tumor. The nurse navigator can fit the woman for a cold cap to preserve her hair and meet her on the first day of chemotherapy for support. Or she might need other tests or treatments, and the nurse navigator can explain those and help her through them. Not all breast cancers are the same.

And not all women are the same, nor do they have the same needs. Both these points were highlighted during a tumor board meeting this summer.

The tumor boards are

weekly meetings between the medical oncologist, the surgeons, the radiologists, pathologist, the nurses, and the social worker. Radiation oncologists, plastic surgeons, genetic counselors, and any others involved in the patients’ care also join. They discuss their cases that week. Typically, the radiologist will start off, to show the extent of the cancer in the breast and whether they believe it has spread. The pathologist will share and confirm with the team what she’s found.

The medical oncologist will discuss the best approach, the type of treatment this cancer responds to best, whether the patient will need chemotherapy. The surgeons consider the type of excisions they can offer the patient. The discussion about treatment is often collaborative, with the surgeons, radiologists, medical oncologist, and geneticists all weighing in. They also discuss cases post-surgery; did they find what they thought they would? Should treatment change in any way?

And then there was a patient we’ll call Deborah. She was a 43-year-old single mother. She needed to come in for surgery, and soon. But she had no one to take care of her children for the 24 hours or so she would need for surgery and recovery. Everyone was worried about her.

Dr. Christina Stevenson, the surgical oncologist and head of the breast program at UConn Health, was the first person to bring up Deborah’s childcare predicament. She’d seen her the day before.

Typically, when Stevenson meets with a patient who needs surgery, they discuss surgical options: just the lump, or the whole breast? Perhaps the woman wants a reduction done at the same time, or implants put in for reconstruction, or her own tissue used instead of implants. Stevenson often consults with a plastic surgeon,

and she does what is called oncoplastic surgery.

“I always try to preserve the breast in a lumpectomy to have the same size and shape we started with,” she says. “People worry they’ll have a divot. But we can move tissue around to help with the appearance.” She also has a few technological tricks, like the Biozorb sitting on her desk. It looks like an inch-long spring made of clear plastic. It’s actually resorbable suture material, studded with little metal clips. The sutures give a scaffold for the tissue to regrow upon, while the metal clips show up on a CAT scan or mammogram and help to focus radiation treatments, as well as follow-up in the future.

Stevenson is very calm describing all this; talking to her about breast surgery is almost soothing. Above her desk is an excerpt of a Christian prayer often attributed to Mother Teresa: “Dear Lord, Give skill to my hand, clear vision to my mind, kindness and meekness to my heart. Give me singleness of purpose and strength to lift up a part of the burden of my suffering fellow man.”

Stevenson brought up Deborah’s case at the tumor board. The social worker and nurse and community navigators stepped in. Although it’s more common for the community navigators to set up rides to appointments, provide gas cards, or fit patients for a nice wig, their goal is to make it possible for women to get treatment. The social worker focuses on psychosocial needs, and here was a woman with very limited social support. The social worker spoke with Deborah often, exploring who could care for her children within her family and community. Eventually Deborah worked

past her anxiety and began to make concrete decisions. After much discussion, she found it in herself to speak with her sister and ask for assistance in caring for her kids while she was in recovery. Her friend drove her to and from surgery. Thanks to everyone stepping up, Deborah was able to successfully complete the initial phase of her treatment.

After surgery, Stevenson follows up with the patient at 1.5 weeks, then three months, then every three to six months for two years, often alternating visits with the medical oncologist. Then, if all is well, the patient comes back for yearly mammograms for life. She comes in for her scans and her cookies and juice and, hopefully, gets the all-clear. And if not, then Stevenson and the rest of the team at UConn Health’s breast program will help her take care of it.

“Because breast cancer is fairly easy to treat, typically. Especially when we catch it early,” Stevenson says. “And when we do regular mammograms, we catch it early.

We try to reduce

the ambiguity:

e ither you're OK, or

you're not.

14 UConn Health Journal

Dr. Christina Stevenson, surgical oncologist and breast program head, in the operating room. Nurse navigators and nurses like Minal Dave, RN,

often offer patients emotional support.

”

THE DOCTOR IS IN

Dr. Kwame Amankwah may be new to UConn Health, but he has already made a big impact on the Department of Vascular and Endovascular Surgery.

In his first few months, he performed an aortic dissection repair with a newly approved device that not only covers the tear that caused the dissection but also helps to heal the rest of the aorta and prevent further tears from developing. It was the first procedure with this device at UConn and the second in the state. Amankwah had performed this same procedure in New York, the first of its kind in that state and only the second in the country.

Throughout his career, Amankwah has been among the first to use new technologies for inferior vena cava filters, devices for aortic work, therapies for the removal of clots within the arterial

and venous systems, and a device for patients with pulmonary embolisms. The pulmonary embolism device was eventually approved for use in the U.S., and Amankwah was on the data safety review board for the study. He brings all

of his experience and expertise to UConn Health. “The goal of all of this is to make UConn a destination center for vascular and endovascular care in the region,” he says.

Amankwah feels the best place to cultivate innovative technology and care is at an academic medical center.

“You get the benefits of interacting with different people, including basic science researchers and

clinicians in other departments who are involved in cutting-edge research of their own,” he says. “At an academic medical center, you get a global view of different technologies and different specialties, and you might be able to incorporate some

of those things into your own practice.”

Another benefit of working at an academic medical facility, he says, is shaping the future of medicine by working with medical students and residents. Amankwah’s background is steeped in education, and he even writes questions for many national medical exams for medical students and residents.

Looking to the future, Amankwah hopes to offer more new therapies to his patients, specifically new endovascular devices used for thoracoabdominal aneurysms with an upcoming clinical trial that he plans to participate in. “There’s always new technology on the horizon in vascular surgery,” he says. “It’s an exciting time to be practicing medicine.”

17

New Vascular Surgery Chief Stays a Step Ahead

— Dr. Kwame Amankwah, Department of Vascular and Endovascular Surgery

“

“

Dr. Kwame AmankwahFarmington1-84-GET-UCONN

Clinical Interests• Endovascular medicine• Vascular medicine• Vascular surgery

Education & Training: • MD, Albany Medical College• Internship and residency

in general surgery, SUNY Downstate Health Sciences University at Brooklyn

• Fellowship in vascular surgery, Yale University School of Medicine

• Fellowship in endovascular and interventional radiology, Texas Tech University

Fall 201916

Healthy Aging

Q Why should a patient see a geriatrician?

At our multidisciplinary geriatric clinic, we see older adults who wish to maintain their health, function, and independence, as well as those facing a crisis. Geriatricians are specialists on the complex issues arising from having multiple coexisting chronic diseases, multiple medications, and multiple providers. We work with each patient and their family and referring physician to come up with an optimal plan that meets their unique needs and goals.

Q What is the Center on Aging doing to address

the unique challenges related to hospitalization in this population?

At most hospitals, nearly half the inpatients are 65 years old and older. To raise the overall level of care for these patients, we bring together all of the providers they need — physicians, nurses, physical therapists, social workers.

With older adults, the greatest challenges associated with hospitalization include delirium, falls, and declines in mobility. We’re actively involved in several National Institutes of Health–funded research efforts to improve outcomes after hospitalization, including the Starting a Testosterone and Exercise Program after Hip Injury, or STEP-HI, study to improve function in women who’ve broken a hip. A few years ago, we joined the NICHE program (Nurses Improving Care

for Healthsystem Elders), a nursing-led multidisciplinary strategy to improve outcomes for hospitalized patients. None of this can be accomplished without engagement and leadership by nurses.

Q What makes older patients more likely to be readmitted

during post-op/recovery?

Bed rest leads to loss of muscle strength, which happens quickly in older adults. Many people continue to need monitoring or help with medications after hospitalization, which may require a stay in an intermediate facility for rehabilitation. When transitioning from one institution to another, there’s potential for some real gaps in care, such as medication errors.

Transitional care programs like the ones at our partner rehabilitation facilities — where one of our physicians provides care during post-acute rehabilitation — help to overcome these challenges. The physician’s work is integrated with the work of the discharge planners and the care team here; they’re familiar with the protocols; and they have access to our electronic medical record system. There’s seamless communication and a continuity of care. We’ve seen noticeable reductions in our hospital readmission rates among patients under the care of our physicians in skilled nursing facilities. The best example of this is at Avon Health Center, where we’ve seen a 77% reduction in the 30-day readmission rate in the three-plus years we’ve had a physician assigned there.

According to the U.S. Census Bureau, the number of Americans over 65 is expected to almost double by 2060. An aging population means caring for more Americans living with cancer, obesity, and Alzheimer’s disease, among other challenges. UConn Health Journal asked gerontologist Dr. George Kuchel about the key phases of geriatric care.

Dr. George Kuchel Director, UConn Center

on Aging; Travelers Chair in Geriatrics and Gerontology,

UConn School of Medicine

UConn Health Journal

UCONN EXAMINES

The STEP-HI study is enrolling participants. Women ages 65 and older with a recent hip fracture can contact study coordinator Heather McAbee-Sevick to learn how to participate in this study: 860-679-6115 or mcabeesevick@uchc.edu. IRB#O18-075-2

Nonprofit Org.U.S. POSTAGE

PAIDStorrs, CT

Permit No. 3UConn Health Journal263 Farmington AvenueFarmington, CT 06030-19151-84-GET-UCONN

Dedicated Line for Referring Physicians 860.679.5555• Make patient appointments• Arrange patient admissions• Engage in physician-to-physician consultation• Obtain general information and assistance

Contact practicerelations@uchc.edu for general information or for assistance regarding the resources, education, and referral information UConn Health requires.

When an injury disrupts your life and affects your mobility, trust the experts at UConn

Health to get you back on your feet. As the area’s only academic medical center, we offer advanced treatment based on decades of experience to get you better faster and back to doing what you love.

Learn more about UConn Health Orthopedics & Sports Medicine. h.uconn.edu/osm

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